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Issues Facing the Nurse Practitioner
Ashley R. Salter
Saint Luke’s College of Health Sciences
Many issues and struggles face Nurse Practitioners in the medical field. There are many positive and negative aspects of the role of the Nurse Practitioner when it comes to defining boundaries and their scope of practice (Kilpatrick, K. et al, 2011). Scope of practice can be defined as boundaries, rules, and regulations in which a Nurse Practitioner may practice under (Kleinpell, R. et al., 2011). The purpose of this paper is to review the challenges of working as a Nurse Practitioner focusing on acute care. Scope of practice as it relates to the NP is very hard to define, and must further be clarified especially in acute care (Kleinpell, R. et al., 2011). The Acute Care Nurse Practitioner, (ACNP), is a combination of nursing and medical professions (Kilpatrick, K. et al, 2012).
Evidence based research proves that there is an increase in demand for ACNPs who are highly qualified to be a part of the medical team (McCarthy, C. et al, 2013). In Kosevich et al.’s (2012) journal, states “The nurse practitioner assumes a wide variety of roles in the clinical setting including direct patient care, case management, care consultation and collaboration, patient education/facilitation of self-management, expert/consultant, and researcher” (McCarty, C. et al., 2013). The ACNP works in collaboration with a physician and independently to manage care of a group of patients.
A negative aspect of NP’s is introduced as some physicians are concerned with NPs regarding their preparedness and readiness for their responsibilities (Kilpatrick, K. et al., 2011). It is noted that every physician has different expectations for every NP role (Kilpatrick, K. et al., 2011). In Kilpatrick, K. et al.’s 2011 study found that professional groups such as physicians, pharmacists, and experienced staff nurses felt as if they needed to be consulted more often and included in patient care. Some medical staff noted that their role became less important as they had fewer interactions with doctors and their knowledge of their patients decreased due to NPs performing patient rounds (Kilpatrick, K. et al., 2011). Some physicians believed that ACNPs were in between the medical and nursing field, while others believed that the ACNP role was equal to the role as of a junior resident (Kilpatrick, K. et al., 2011). This is why many people believe ACNPs are complicating boundaries between both fields.
Amongst the issues, it was found the greatest issue was the ACNP prescribing medications. Some physicians felt that “the role of prescribing is part of the physician’s identity. The ability to prescribe is one of the only things that differentiates a physician from anyone else” (Kilpatrick, K. et al., 2011). This can be seen as a threat by physicians from transferring the prescriptive role to the NPs. In a study of 209 participants in 2013, 78% of NPs reported that they prescribe medications with 23% of the participants stating they do not prescribe medications (Buckley, T. et al., 2013).
Clinical decision making is a term used for NP training that is needed to increase knowledge in order to make the best decisions when managing patients (Tiffen, J. et al., 2014). Clinical decision making is further defined as “the process of choosing between alternatives or options. It is a complex process where data are gathered and evaluated, and then a decision, judgement, or intervention is formulated (Tiffen, J. et al., 2014). Education will strengthen and develop the NP to prepare for application and expertise in their career (Tiffen, J. et al., 2014). Weighing the options of and potential risks of decision making will impact the NPs actions and choices. Clinical decision making was later interpreted as an ever changing process where data is applied and evaluated to impact a decision.
NPs after gaining experience rely on intuition to develop decision making. As NPs grow in their careers, they look for patterns and underlying causes and themes in determining what is relevant and what is not in their choices for treatment (Tiffen, J. et al., 2014). The idea of intuition is criticized because it is looked at as a guessing game rather than evidence. Newer NPs with few experience mostly rely on analytical principles and guidelines in determining decisions.
Professional organizations have a direct impact in updating and redefining NPs scope of practice. The scope of practice is very broad and it varies on the type of specialty and practice (Kleinpell, R. et al., 2011). Examples of NP services include “ordering, conducting, supervising, and interpreting diagnostic and laboratory tests, and prescribing pharmacologic agents and nonpharmacologic therapies. Teaching and counseling individuals, families, and groups are also identified as major parts of NP practice” (Kleinpell, R. et al., 2011). This is why education in acute care is important in making decisions for critical and complex health conditions. Acute Care Nurse Practitioners may practice in hospital settings such as intensive care units, emergency rooms, and sub-acute care, and urgent care centers. This also may include office or home settings, rehab or palliative care (Kleinpell, R. et al., 2011). An example of where a family NP may not practice in acute care settings is even if they have worked as a registered nurse in an intensive care unit or emergency department, would not be able to practice as an NP due to their education and training and different focus of care, which would be considered outside of their scope of practice in acute care settings (Kleinpell, R. et al., 2011).
Another issue NPs face is whether or not their quality of care and expertise is as high enough of that of a physician (Mundinger, M. et al., 2000). Patient satisfaction levels as well as their health status comparing care of physicians vs. NPs, were examined in Mundinger, M. et al.’s, 2000 study concluded that patient outcomes were comparable of physicians and NPs. This was assessed by patients being randomly selected to care by either healthcare provider where NPs had the same responsibilities and authority in decision making (Mundinger, M. et al., 2000). This was assessed by patient follow ups after six months after care provided, and then again at one year following (Mundinger, M. et al., 2000).
The aging population and higher demand for critical and acute care services due to physician shortages and structured resident hours have impacted the growth of NPs as well as physician assistants (McCarthy, C. et al., 2013). This allows for NPs to be integrated into the medical teams. However, NPs scope of practice varies state to state. In 2013, it was shown that 16 states, “ACNPs had authority and no supervision or collaboration with a physician is required” (McCarthy, C. et al.,2013). In the other residing states, they do require NPs are supervised by a physician and the legal terms are regulated by each state board of nursing and state board of medicine.
Billing and coding is another aspect of challenges NPs have faced deciding whether billing is the same between NPs and physicians. In 2013, a report showing critical care was billed the same as for physicians, however not all patients in critical care settings met the criteria for billing and codes (McCarthy, C. et al., 2013). Documentation is critical in performing services to patients for the actual time spent on the NPs and physician’s services. In situations where NPS and physicians are rounding on same patients together, they cannot bill the patient separately for services. Only one provider would be able to claim the time spent seeing the patient when times overlap (McCarthy, C. et al., 2013).
Nurse Practitioners expanding their roles come to face numerous issues in reaching their full potential in scope of practice including “lack of medical acceptance of the roles, lack of organizational and administrative supports, and a lack of understanding of the roles by team members…such conflicts may explain the turf wars between professional groups that emerge when nurse practitioner roles are introduced” (Kilpatrick, K. et al., 2012). Practicing autonomy is an integral part of the role as a nurse practitioner. This decision making autonomy directly affects how NPs are influenced by their roles in the medical and expanse of nursing practice (Kilpatrick, K. et al., 2012). Further research is needed to develop a well defined scope of practice for NPs in their contribution to patient care to eliminate healthcare role confusion.
Participants in a study researching “Boundary work and the introduction of acute care nurse practitioners in healthcare teams”, determined a list of concepts participants found as the need to “create space” for the new role of ACNPs (Kilpatrick, K. et al., 2011). Creating space for oncoming NPs was an adjustment for healthcare providers to accommodate for the new role in the team and incorporate the NPs into their daily routines. Other barriers included Loss of valued functions for example nurses lost contact with physicians due to the medical team of physicians seeking NPs for information. The staff nurses were no longer the direct line to receive patient information. This was a feeling of a need to re-organize nurses’ activities and to adapt to new role expectations and changes in work priorities (Kilpatrick, K. et al., 2011). Trust among team members, inter-personal dynamics by taking time out to listen to other health care providers, and time as it relates to the ACNP’s role constantly evolving and shifting with providers being reluctant to give up some of their duties over time (Kilpatrick, K. et al., 2011).
Some countries are going away from acute care and investing more time in preventative care and improving health. This is known as anticipatory care, or “working with individuals to help them identify early any circumstances, which may have a negative impact on their long-term conditions, and supporting them to develop strategies to avoid them or reduce their effects” (Kennedy, C. et al., 2010). Examples include risk screenings, early start of treatment, improving health and accessing services. A disadvantage of anticipatory care could be receptiveness of patient’s ability to learn or their education or a lack of resources available (Kennedy, C. et al, 2010).
The ACNP role has encouraged continuity of care. It is patient centered care that increases self-care, getting patients to perform their activities of a daily living and pharmacological and nonpharmacological holistic care that helps with symptom management (Kilpatrick, K. et al., 2010). In Canada in the late 1980s, the ACNP was created due to the increasing physician workloads and the lack of continuity of care for acute care patients. In some areas, regulations of some roles are in place such as initial diagnosis of disease and signing death certificates remain exclusively by physicians (Kilpatrick, K. et al., 2010). Most jurisdictions and regulations however allow ACNPs to per diagnose diseases or conditions, order and interpret diagnostic tests, and prescribe medications. ACNP’s time is split up and it is suggested that 70% of their work is spent in the clinical setting where as 30% is not on clinical settings such as education and research (Kilpatrick, K. et al., 2010).
ACNPs improves decision making by transferring and communicating between nurses and physicians. Communication is key in importance of team effectiveness (Kilpatrick, K., 2012). In a survey among nurses, physicians, residents and interns to discover if there were changes in communication amongst the team with the introduction of a nurse practitioner. The results showed that communication was the biggest advantage ACNPs had in the team and helped facilitate open communication between the providers (Kilpatrick, K., 2012).
NPs act as a consultant or liaison as well. “NPs, by performing many of the functions allocated previously to physiatrists, extends the physicians’ clinical area, allowing them to spend more time in research and medical leadership” (Kosevich, G. et al., 2012). By the ACNP taking on more roles and support for the physician, it allows more time for physicians to spend more time focusing on their roles.
A positive for the role as an ACNP, is the emerging role in emergency medicine is the use of nurse practitioners in this setting. Fast track ACNPs are being used in the emergency department to help with timely discharge of patients. This also helps with overcrowding and decreased amount of time in the ER stay. This expedites the process of discharging patients and working alongside the physician to facilitate a more timely process in the emergency room (Considine, J. et al., 2012).
Overall, communication and decision making amongst the providing team is an important role in ACNPs. Some ACNPs more often communicate with physicians when making care decisions, however others communicate more often with the nurses in the field (Kilpatrick, K., 2012). Delegating by physicians can be a very complex and time consuming process.
By the research and studies out there, it seems that clear boundaries, borders, and scope of practice needs to be clearly defined. Of the literature reviewed, it was difficult finding any concrete definition of what the Acute Care Nurse Practitioners scope of practice actually is. I feel that more research needs to be conducted and investigated in determining the exact scope of practice to protect the ACNP as well as the physicians they work under. “The titles used to identify NPs in acute care are currently in a state of flux…The scope of practice of ACNPs is affected by the delegation of patient care decisions and prescribing authority to the ACNPs” (Kilpatrick, K., 2012).
Boundary work is a point of line where the scope of practice of a provider is established. Most of the time in boundaries, roles were shared between the providers (Kilpatrick, K., et al., 2011). “There has been little research related to the development or shift of boundary lines in healthcare teams following the introduction of ACNP roles” (Kilpatrick, K. et al., 2011). If boundaries are not clearly defined for acute care nurse practitioners, more research should be compiled and clear rules should be established to educate physicians and ACNPs on scope of practice to not cross boundaries that doesn’t apply to ACNPs.
ACNPs are increasingly being used to provide care and the number of ACNPs and roles have increased (Kosevich, G. et al., 2013). As the numbers rise, the more beneficial it is to have ACNPS apart of the healthcare providing team. Although the many challenges and issues they face, the more autonomy and responsibility nurse practitioners have, will improve team dynamics by staying within the boundaries and scope of practice.
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ISSUES FACING THE NURSE PRACTITIONERIssues facing the nurse practitioner15
Running head: Issues facing the nurse practitioner1he titles used to identify NPs in acute care are currently in a state of flux…The scope of practice of ACNPs is affected by the delegation of patient care decisions and prescribing authority to the ACNPs” (Kilpatrick, K., 2012).
Kilpatrick, K., Lavoie-Tremblay, M., Ritchie, J., Lamothe, L.